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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006575
Report Date: 09/09/2024
Date Signed: 09/09/2024 09:49:14 AM

Document Has Been Signed on 09/09/2024 09:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CALM HAVENFACILITY NUMBER:
306006575
ADMINISTRATOR/
DIRECTOR:		TAWFIK, OMARFACILITY TYPE:
735
ADDRESS:2516 W KEYS LANETELEPHONE:
(714) 458-9593
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 4CENSUS: 0DATE:
09/09/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Omar Tawfik, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Rose Ruppert made an announced visit to the facility today to conduct a Prelicensing visit. LPA was greeted and granted entry by Omar Tawfik at 8am. During today’s visit, LPA met with Omar Tawfik, Administrator.

The facility is a level 4i single story building with an approved fire clearance of four ambulatory. All client rooms are private with the required furnishings. The facility currently has a census of no clients in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two client bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 114.4 and 114.6 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on June 1, 2024.

LPA inspected the facility food supply and observed the facility retained seven days of non-perishable food on hand and will have two days of perishable items once there are clients in care. Knives and cleaning supplies are secured under kitchen sink. LPA observed medication storage and a First Aid Kit with all the required components and medication storage is locked. LPA observed the PUB 475 is not the required 20" X 26" size. Visiting hours were posted. LPA confirmed that administrator has a current administrator certificate which expires on March 8, 2025. LPA conducted Component III with Administrator. Administrator will inform licensee when there are clients in care and will follow-up with LPA regarding PUB 475 via email.

The Administrator was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of the report was provided to Licensee.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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